Patients have the right to make their own decisions regarding care and treatment.  Whether the decision is a good decision or not, it is the patient’s decision, as long as it is an “informed decision” and the patient has the capacity to understand and make such decisions. As healthcare professionals the expectation is to provide as much information to the patient to help them make a good, healthy decision. However, in the end, the patient can disagree with the recommended care and treatment that you believe is best.

Patients often leave the hospital, whether it is from the Emergency Department or from the hospital as an inpatient, for any number of reasons. Review of Event Reports over the years have reflected a host of different reasons -- patient anxious to get home to care for significant other; patient disagrees with care and wants to go elsewhere for second opinion; patient wants to get back to work; patient has pet dog at home with no one to feed it; and patient has ice cream in car and it’s melting.  Obviously, some of the reasons are lame; however, some are very legitimate and while you may not appreciate the need for leaving Against Medical Advice (AMA) the patient is compelled to leave the hospital and refuse further care. The question that needs to be answered is - what’s driving the decision? Many times an excuse is given, but that’s not the real reason. Often, avoidance of a financial burden, misunderstanding the care/treatment, fear of diagnosis, or lack of social support may drive a decision. When looking at the big picture, there may be things that the hospital and physician can do to help educate the patient and provide resources to encourage better decision making.

Once a decision is made by the patient to leave Against Medical Advice, then it should be honored and arrangements made to provide for a safe discharge. While the patient is refusing to follow sound medical care, there is the burden to ensure the patient is provided with appropriate, reasonable resources and direction to accommodate their request. It is not acceptable to “wash your hands” of the patient once they have opted out of the proposed treatment plan. 

A discussion with the patient is important to ensure that the patient has the capacity to understand the risks and benefits for proposed treatment and any alternative treatment, including no treatment. Once it is determined that the patient has the capacity to refuse care and wishes to leave, then he/she should be informed of risks/benefits of such decision and asked to sign an AMA form.  If the patient refuses to sign the form, then the refusal to sign should be documented on the form along with date/time/witness. The patient should be provided, as medically determined, prescriptions, follow up appointments, directions to follow up with the Emergency Department and/or specialists, and discharge instructions.

For those scenarios when the patient does not have the capacity to make an informed decision regarding care then the burden is higher to ensure that they do not leave the hospital unless their Power of Attorney or healthcare agent or representative has made a decision on the patient’s behalf and acting on it. 

There are times when patients up and leave the hospital without the opportunity to share their thought process and to discuss their care. These scenarios are considered elopements. Greater care is necessary to try to contact the patient and provide information so their decision becomes an “informed decision.” There are times when the patient does return after being informed of the risks; however, there are times when a patient does not. Efforts to reach the patient should be documented in the medical record along with the follow up actions.

Patient safety is primary responsibility.